CommercialPrior AuthLow impact
State and School Employees' Health Insurance Plan - Brineura (cerliponase alfa)
Blue Cross & Blue Shield of Mississippi·MS · Pediatrics, Neurology·Medical Policy
We identified it
Jun 20, 2026
Summary
This is a comprehensive new medical policy for Brineura (cerliponase alfa) for treating CLN2 disease in pediatric patients. The policy establishes strict prior authorization criteria including specific diagnostic requirements, clinical rating scale scores, and specialist involvement for initial approval and renewals.
Action Required
Immediately: Billing team must ensure prior authorization is obtained for all Brineura (cerliponase alfa) claims using HCPCS code J0567. Verify patients meet all initial criteria including definitive CLN2 diagnosis, Hamburg CLN2 Clinical Rating Scale scores of 3-6, and specialist involvement. For renewals, document positive response to therapy and continued clinical benefit. Claims without proper prior authorization will be denied.